First introduced in the 1980s, automated medication dispensing technology has become ubiquitous over the past few decades. According to Pharmacy Purchasing & Products’ 2016 State of Pharmacy Automation Survey, automated dispensing cabinets (ADCs) are now used by 91% of hospitals across the country, with 68% utilizing ADCs as the primary means of drug dispensing.1 As widespread implementation is commonplace, hospitals must now look to optimize the benefits of this technology to continually increase staff productivity and improve patient care.
The value of ADCs is three-fold: cabinets ensure medication availability, improve workflow, and increase medication safety. ADCs provide nurses quick access to medications, which increases nurses’ satisfaction and ensures patients receive medications in a timely manner. The ADC software offers nurses the ability to queue up medication orders remotely, rather than at the cabinet, streamlining workflow and reducing time spent waiting to access the cabinet. Profiled ADCs ensure pharmacists review medication orders before they are administered to patients, increasing medication safety. To capitalize on these benefits, it is critical to take appropriate steps to maximize use of ADCs by creating a more efficient, safer process that benefits patients, providers, and the organization.
The Role of ADCs at Duke University Hospital
Duke University Hospital is a 957-bed, quaternary care center serving pediatric and adult patients with comprehensive diagnostic and therapeutic capabilities. The facility employs a hybrid drug distribution model, combining medication carousels in the pharmacy and ADCs on the nursing units to leverage medication distribution. ADCs play a vital role in the drug distribution process throughout multiple settings in the health system, including the inpatient and outpatient environments, clinics, and procedural areas. In total, we operate 255 ADCs, 71 of which are specialized anesthesia workstations used in operating rooms. The pharmacy department provides approximately 70% of medications for the typical adult unit via ADCs, with the remainder of medication needs serviced through cart-fill or new doses.
Beyond these traditional applications, we use ADCs inside our cleanrooms to ensure controlled substance accountability in that space. ADCs also are used to ensure drug security for specific high-risk agents, such as U500 insulin and neuromuscular blocking agents, and to better track costly medications, such as blood factors, which demand a higher level of inventory control.
Selecting and Implementing New ADCs
Several years ago, it became clear that Duke University Hospital needed to select and implement new ADC technology, as the cabinets we had been using were no longer being supported based on their hardware and computing platform. The current vendor notified us that our cabinet model would no longer be supported, which created an urgency to begin a request for proposal process. Using a multidisciplinary approach, including pharmacists, pharmacy technicians, nurses, providers, IT, and hospital administration, we evaluated ADC vendors to identify a technology solution that met the multifaceted needs of our organization and selected a cabinet that increased safety and efficiency while integrating easily into our system.
Required features included a controlled substance dispensing module to enable single-dose dispensing, a technology that aids in diversion prevention and eliminates count-backs for nurses, saving time during medication dispensing. In addition, we sought out a cabinet that increases medication safety by requiring bar code scanning upon stocking. Finally, the availability of guiding lights that direct nurses to specific areas within the medication drawer was important in the decision-making process. This feature increases efficiency and ensures that the correct medications are selected from the cabinet.
Onsite vendor support was crucial during the ADC implementation period. We converted one nursing unit (ie, two cabinets) weekly to the new ADCs. Cabinets were shipped to our site, configured, loaded within the pharmacy, and then exchanged on the unit. We first installed the cabinetry, then phased in profiling, which was new to our facility.
In addition, effective staff training for pharmacy and nursing users was critical to success. Our strategy of developing specific training scripts for both pharmacy and nursing users has proven particularly effective (see SIDEBAR: Sample of Profiled ADC Training Script). Following a script standardizes the training process and ensures trainers convey all critical pieces of information to all employees. Utilizing a training script also has proven an effective method of onboarding new users.
In addition to this training, we also offer an advanced ADC course for select pharmacy technicians, which is presented by the hospital’s ADC technician specialist. Technicians are instructed in servicing the ADCs and performing simple maintenance—for example, how to replace buttons, bars, and safety lights. This approach ensures the cabinets are well maintained, while also offering the technicians a valuable advancement opportunity.
Profiling and Overriding Medications
To ensure pharmacist review of medications prior to administration, all ADCs for inpatients are profiled, as are those in the outpatient oncology treatment center and other specialty clinics. Our override strategy is consistent with guidance from the Institute for Safe Medication Practices (ISMP), with condition-based needs—such as pain, anaphylaxis, and acute exacerbation of asthma—used to generate the override list. The senior pharmacy management team is responsible for reviewing new override and cabinet stocking requests.
Target override rates are set and monitored in both ICU and non-ICU environments, and are tracked monthly using a dashboard. While our preference is that all medications undergo a pharmacist review, we understand that there are urgent situations that require immediate medication access. As such, every effort is made to balance these needs by limiting medication overrides to those that are truly necessary. Monitoring our standard override rates enables us to set goals in line with ISMP recommendations that are sensible for our facility.
Employing bar code scanning at the point of restocking adds an additional layer of medication safety. This safety feature is utilized in targeted high-risk areas, including pediatrics, and for substances on the hospital’s high-alert medication list. Medications that are at risk for error based on hospital-specific data, as well as look-alike/sound-alike medications, are triaged based on data published by ISMP and other organizations. For example, ferrous sulfate tablets are triaged for bar code scanning upon stocking because they are similar in appearance to multivitamins and are therefore at risk for stocking errors.
Electronic Health Record Data and Reporting
Leveraging electronic health record (EHR) data to identify areas of ADC optimization increases ADC functionality. To facilitate this process, pharmacy evaluates cart fill data and monitors prescribing trends, both seasonally and over the year as a whole. This data enables us to make available in ADCs the most commonly used medications and efficiently distribute items used on a PRN frequency, as well as those for which quick access increases nursing satisfaction.
For example, it is helpful to administer faster acting blood pressure medications immediately, and as such, nurses require quick access. By including these medications in our standard cabinet fills, we were able to improve nursing satisfaction. Similarly, providing immediate access to antibiotics in areas that treat febrile neutropenic or sepsis patients eliminates transport time from pharmacy and ensures patients receive these vital medications in a timely manner.
In our ongoing efforts to maximize ADC operations, we developed a number of in-house reporting measures in a dashboard. The dashboard includes features that we believe to be proxy measures for how well the operation is performing, such as the following:
- Stock-Out Rate. Measuring how often a nurse finds a medication inventory exhausted is calculated by dividing the number of stock-outs that have occurred by the total number of withdrawal transactions by nursing. Stock-outs act as a predictor that indicates how well we are managing changes in usage against cabinet inventory. Our goal is to measure stability in the stock-out rate.
- Number of Doses Restocked per Technician. It is critical to monitor each technician’s workload to ensure efficiency. We also monitor the run time and the time it takes to complete a cabinet restock.
- Expired Volume and Expense. Measuring which drugs expire in the cabinets and using that as a measure to continually update par levels helps improve inventory management.
Optimizing Cabinet Configuration
Reorganizing the layout of medications within the cabinets can have an instant impact on workflow. Thus, pharmacy continually evaluates the effects of different layout patterns both on pharmacy restock times and nurse efficiency. Our goal is to minimize the number of steps for nursing and pharmacy during the medication distribution process.
Strategies to improve ADC configuration include monthly review of par levels, as well as evaluating medications that have not been used within 30, 60, and 90 days for removal. We have implemented a rotation schedule whereby medications included in the cabinets are reviewed to ensure inventory is always optimized for a specific area’s needs and circulated through the department’s cabinets accordingly.
Rather than setting ADC restocking times solely using days’ supply calculations, we also evaluate high-volume and low-cost medications to identify ways to increase the efficiency of the pharmacy restocking process. If the cabinet has adequate capacity, a large par number of these medications can be stored, allowing us to restock less frequently (ie, once every few weeks to once a month). This method has proven effective for low-cost medications, such as acetaminophen. Analyzing restock data for low-cost items has allowed us to use cabinet space to store a large supply so that when we restock, it is more impactful. Volume increases can be accomplished while keeping the support resources stable and minimizing the number of trips needed to restock medications.
Future goals for drug distribution improvements at our organization include:
- Linking ADC Transactions to the Electronic Medication Administration Record. Implementing technology to link ADC transactions to the electronic medication administration record will enable real-time data and integration between these two systems. With this approach, robust tracking will be a reality—beyond simply recording the user who accessed the medication, this integration would also provide a confirmation of medication administration and detect any inconsistencies. Ideally, we would also have the ability to connect medication administration and waste to cabinet withdrawals, ensuring a complete accounting for all agents.
- Leveraging Enterprise-Level Data. Another goal for our facility is to utilize enterprise-level data to increase inventory efficiency across all of our facilities. Gaining insight into inventory across facilities will lead to improved shortage management and help rebalance inventory levels among different areas within the system based on highest areas of need and use.
- Improved Par-Level Management. We also aim to develop a standardized process for the proactive adjustment of par levels. Par level management is currently a manual process that is contingent on the knowledge and experience of the restocking technician (eg, familiarity with product sizes and drawer capacities). In the future, we envision an automated process, wherein the system would have the ability to automatically assign par levels and drawer locations based on an agent’s size.
Implementing ADCs is simply the first step toward efficient medication distribution and safety; hospitals must continually identify new ways to maximize ADC use. Enhancing cabinet performance benefits pharmacy staff and increases end-user satisfaction while improving the ability to care for our patients.
- State of Pharmacy Automation. Automated Dispensing Cabinets. Pharm Purch Prod. 2016;13(8):60-63.
- Institute for Safe Medication Practices. ISMP Guidance on the Interdisciplinary Safe Use of Automated Dispensing Cabinets. www.ismp.org/tools/guidelines/ADC_Guidelines_final.pdf. Accessed December 21, 2016.
Matthew J. Kelm, PharmD, MHA, is the manager of unit dose distribution in the department of pharmacy at Duke University Hospital. He earned his Doctor of Pharmacy from Purdue University in 2006 and Masters in Healthcare Administration from the University of North Carolina – Chapel Hill in 2012. Matthew’s professional responsibilities encompass central pharmacy operations, including controlled substance management, automated dispensing cabinet operations, and non-sterile dose preparation and distribution.
Sample of Profiled ADC Training Script
Restocking a Medication (Ketorolac 30 mg vial)
1. Touch INVENTORY MENU
2. Touch SUPPLEMENTAL RESTOCK on the left
3. Find Ketorolac by typing the first few letters or scroll using the touch screen or the keyboard
4. Select Ketorolac 30 mg vial
5. Type in the restock quantity of 1
6. Touch OK
Note: To restock more than one medication, select the other medications at this step. The quantities are indicated on the left side of the items. The DISPLAY MEDS TO RESTOCK menu can also be used to see all the items that have been selected prior to beginning the restock.
7. Touch RESTOCK MEDS NOW
8. Press flashing button on drawer and then pull it out all the way
9. Identify and open the Ketorolac bin by using the flashing light or the bin numbering system (Note: Items stocked in locked bins must be pulled up twice to open)
10. Use the scanner to scan item for verification
11. Scan bin bar code for verification
12. Enter the earliest expiration date if it is before the date indicated on the screen
13. Verify that the count in the bin matches the prior bin level indicated on the screen. This step is crucial. If the count needs to be changed, press the CHANGE BIN LEVEL button on the top right, enter the correct number, and press OK
14. Restock the bin and close the bin and drawer
Note: If working on a locked bin and it accidentally closes, it can immediately be reopened by indicating so on the screen.
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